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Kijpaisalratana N, Ament Z, Patki A, Bhave VM, Jones AC, Garcia Guarniz AL, Couch CA, Cushman M, Long DL, Irvin MR, Kimberly WT. Acetylglutamine Differentially Associated with First-Time Versus Recurrent Stroke. Transl Stroke Res 2024; 15:941-949. [PMID: 37531033 PMCID: PMC10834852 DOI: 10.1007/s12975-023-01181-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 07/10/2023] [Accepted: 07/24/2023] [Indexed: 08/03/2023]
Abstract
Approximately one-quarter of strokes occur in individuals with prior stroke. Despite the advancement in secondary stroke prevention, the long-term risk of recurrent stroke has remained unchanged. The objective of this study was to identify metabolite risk markers that are associated with recurrent stroke. We performed targeted metabolomic profiling of 162 metabolites by liquid chromatography-tandem mass spectrometry in baseline plasma in a stroke case-cohort study nested within the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study, an observational cohort study of 30,239 individuals aged 45 and older enrolled in 2003-2007. Weighted Cox proportional hazard models were used to identify metabolites that had a differential effect on first-time versus recurrent stroke using an interaction term between metabolite and prior stroke at baseline (yes or no). The study included 1391 incident stroke cases identified during 7.1 ± 4.5 years of follow-up and 1050 participants in the random cohort sample. Among 162 metabolites, 13 candidates had a metabolite-by-prior stroke interaction at a p-value <0.05, with one metabolite, acetylglutamine, surpassing the Bonferroni adjusted p-value threshold (p for interaction = 5.78 × 10-5). In an adjusted model that included traditional stroke risk factors, acetylglutamine was associated with recurrent stroke (HR = 2.27 per SD increment, 95% CI = 1.60-3.20, p = 3.52 × 10-6) but not with first-time stroke (HR = 0.96 per SD increment, 95% CI = 0.87-1.06, p = 0.44). Acetylglutamine was associated with recurrent stroke but not first-time stroke, independent of traditional stroke risk factors. Future studies are warranted to elucidate the pathogenesis of acetylglutamine and recurrent stroke risk.
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Affiliation(s)
- Naruchorn Kijpaisalratana
- Center for Genomic Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Division of Neurology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Division of Academic Affairs, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Department of Neurology, Massachusetts General Hospital, Boston, MA, 02114, USA
| | - Zsuzsanna Ament
- Center for Genomic Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Neurology, Massachusetts General Hospital, Boston, MA, 02114, USA
| | - Amit Patki
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA
| | | | - Alana C Jones
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA
| | | | - Catharine A Couch
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Mary Cushman
- Department of Medicine, Larner College of Medicine at the University of Vermont, Burlington, VT, USA
| | - D Leann Long
- Department of Biostatistics, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA
| | - M Ryan Irvin
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA
| | - W Taylor Kimberly
- Center for Genomic Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
- Department of Neurology, Massachusetts General Hospital, Boston, MA, 02114, USA.
- Harvard Medical School, Boston, MA, USA.
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Nakada S, Ho FK, Celis‐Morales C, Pell JP. Schizophrenia and Types of Stroke: A Mendelian Randomization Study. J Am Heart Assoc 2024; 13:e032011. [PMID: 38420769 PMCID: PMC10944050 DOI: 10.1161/jaha.123.032011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 11/22/2023] [Indexed: 03/02/2024]
Abstract
BACKGROUND Previous studies suggest an association between schizophrenia and stroke, but no studies have investigated stroke subtypes. We examined potential causal associations between schizophrenia and a range of atherosclerotic, embolic, and hemorrhagic stroke outcomes. METHODS AND RESULTS Two-sample Mendelian randomization analyses were conducted. The summary-level data (restricted to European ancestry) were obtained for schizophrenia and stroke: ischemic stroke, large-artery stroke, small-vessel stroke, cardioembolic stroke, and intracerebral hemorrhage. The associations between schizophrenia and each outcome were analyzed by an inverse variance weighting method primarily and Mendelian randomization Egger, weighted median, and weighted mode subsequently. The presence of pleiotropy was also tested by Cochran Q statistic, I2 index, and Mendelian randomization Egger intercept with scatter and funnel plots. We found associations between schizophrenia and cardioembolic stroke (odds ratio [OR], 1.070 [95% CI, 1.023-1.119]) and intracerebral hemorrhage (OR, 1.089 [95% CI, 1.005-1.180]) using inverse variance weighting. Little evidence of associations with the other stroke subtypes was found. Different Mendelian randomization methods corroborated the association with cardioembolic stroke but not intracerebral hemorrhage. CONCLUSIONS We have provided evidence of a potentially causal association between schizophrenia and cardioembolic stroke. Our findings suggest that cardiac evaluation should be considered for those with schizophrenia.
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Affiliation(s)
- Shinya Nakada
- School of Health and WellbeingUniversity of GlasgowGlasgowUnited Kingdom
| | - Frederick K. Ho
- School of Health and WellbeingUniversity of GlasgowGlasgowUnited Kingdom
| | - Carlos Celis‐Morales
- School of Health and WellbeingUniversity of GlasgowGlasgowUnited Kingdom
- School of Cardiovascular and Metabolic HealthUniversity of GlasgowUnited Kingdom
- Human Performance Laboratory, Education, Physical Activity and Health Research UnitUniversidad Católica del MauleTalcaChile
| | - Jill P. Pell
- School of Health and WellbeingUniversity of GlasgowGlasgowUnited Kingdom
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Health care providers’ effect on long-term mortality after the first-ever stroke: application of shared frailty survival models. Neurol Sci 2022; 43:4307-4313. [DOI: 10.1007/s10072-022-05983-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 02/24/2022] [Indexed: 11/27/2022]
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Del Brutto VJ, Rundek T, Sacco RL. Prognosis After Stroke. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00017-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Portegijs S, Ong AY, Halbesma N, Hutchison A, Sudlow CLM, Jackson CA. Long-term mortality and recurrent vascular events in lacunar versus non-lacunar ischaemic stroke: A cohort study. Eur Stroke J 2021; 7:57-65. [PMID: 35287300 PMCID: PMC8915237 DOI: 10.1177/23969873211062019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 11/04/2021] [Indexed: 11/16/2022] Open
Abstract
Introduction Studies of differences in very long-term outcomes between people with lacunar/small vessel disease (SVD) versus other types of ischaemic stroke report mixed findings, with limited data on myocardial infarction (MI). We investigated whether long-term mortality, recurrent stroke and MI risks differ in people with versus without lacunar/SVD ischaemic stroke. Patients and methods We included first-ever strokes from a hospital-based stroke cohort study recruited in 2002–2005. We compared risks of death, recurrent stroke and MI during follow-up among lacunar/SVD versus other ischaemic stroke subtypes using Cox regression, adjusting for confounding factors. Results We included 812 participants, 283 with lacunar/SVD ischaemic stroke and 529 with other stroke. During a median of 9.2 years (interquartile range 3.1–11.8), there were 519 deaths, 181 recurrent strokes and 79 MIs. Lacunar/SVD stroke was associated with lower mortality (adjusted HR 0.79, 95% CI 0.65 to 0.95), largely due to markedly lower all-cause mortality in the first year. From one year onwards this difference attenuated, with all-cause mortality only slightly and not statistically significantly lower in the lacunar/SVD group (0.86, 95% CI 0.70 to 1.05). There was no clear difference in risk of recurrent stroke (HR 0.84, 95% CI 0.61–1.15) or MI (HR 0.83, 95% CI 0.52–1.34). Conclusion Long-term risks of all-cause mortality, recurrent stroke and MI are similar, or only slightly lower, in patients with lacunar/SVD as compared to other ischaemic stroke. Patients and physicians should be as vigilant in optimising short- and long-term secondary prevention of vascular events in lacunar/SVD as for other stroke types.
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Affiliation(s)
- Suzanne Portegijs
- Usher Institute, University of Edinburgh, Edinburgh, Scotland
- Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | | | - Nynke Halbesma
- Usher Institute, University of Edinburgh, Edinburgh, Scotland
| | - Aidan Hutchison
- Usher Institute, University of Edinburgh, Edinburgh, Scotland
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, Scotland
| | - Cathie LM Sudlow
- Usher Institute, University of Edinburgh, Edinburgh, Scotland
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, Scotland
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Kolmos M, Christoffersen L, Kruuse C. Recurrent Ischemic Stroke - A Systematic Review and Meta-Analysis. J Stroke Cerebrovasc Dis 2021; 30:105935. [PMID: 34153594 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105935] [Citation(s) in RCA: 71] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Revised: 05/20/2021] [Accepted: 05/29/2021] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVES Recurrent stroke remains a challenge though secondary prevention is initiated immediately post-stroke. Stroke subtype may determine the risk of recurrent stroke and require specific preventive measures. We aimed to identify subtype-specific stroke recurrence and associated risk factors over time. METHODS AND MATERIALS A systematic review was performed using PubMed and Embase for studies including adults >18 years, first-ever ischemic stroke in population-based observational studies or registries, documented TOAST-criteria and minimum 1-year follow-up. Meta-analysis on stroke recurrence rate was performed. Final search: November 2019. RESULTS The search retrieved 26 studies (between 1997 and 2019). Stroke recurrence rate ranged from 5.7% to 51.3%. Recurrent stroke was most frequent in large artery atherosclerosis (LAA) and cardioembolic (CE) stroke with recurrent stroke similar to index stroke subtype. We identified a lower recurrence rate for small vessel occlusion (SVO) stroke with recurrence frequently of another stroke subtype. Based on a meta-analysis the summary proportion recurrence rate of recurrent stroke in studies using TOAST-criteria = 0.12 and = 0.14 in studies using TOAST-like criteria. Hypertension, diabetes mellitus, atrial fibrillation previous transient ischemic attack, and high stroke severity were independent risk factors for recurrence. CONCLUSION Stroke recurrence rates seem unchanged over time despite the use of secondary prevention. The highest recurrence rate is in LAA and CE stroke eliciting same subtype recurrent stroke. A lower recurrence rate is seen with SVO stroke with a more diverse recurrence pattern. Extensive workup is important in all stroke subtypes - including SVO stroke. Future research needs to identify better preventive treatment and improve compliance to risk factor prevention to reduce stroke recurrence.
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Affiliation(s)
- Mia Kolmos
- Herlev Gentofte Hospital, Department of Neurology, Neurovascular Research, Unit, Denmark
| | | | - Christina Kruuse
- Herlev Gentofte Hospital, Department of Neurology, Neurovascular Research Unit, Denmark.
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Lin WQ, Cai ZJ, Chen T, Liu MB, Li N, Zheng B. Cost-Effectiveness of Dipeptidylpeptidase-4 Inhibitors Added to Metformin in Patients With Type 2 Diabetes in China. Front Endocrinol (Lausanne) 2021; 12:684960. [PMID: 34484112 PMCID: PMC8415028 DOI: 10.3389/fendo.2021.684960] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 07/23/2021] [Indexed: 12/29/2022] Open
Abstract
PURPOSE Dipeptidylpeptidase-4 (DPP-4) inhibitors, including linagliptin, alogliptin, saxagliptin, sitagliptin, and vildagliptin, are used for the treatment of type 2 diabetes mellitus (T2DM) patients in China. This study assessed the economic outcomes of different DPP-4 inhibitors in patients with T2DM inadequately controlled with metformin in the Chinese context. MATERIALS AND METHODS In this study, the validated Chinese Outcomes Model for T2DM (COMT) was conducted to project economic outcomes from the perspective of Chinese healthcare service providers. Efficacy and safety, medical expenditure, and utility data were derived from the literature, which were assigned to model variables. The primary outputs of the model included the lifetime costs, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratio (ICER). One-way and probability sensitivity analysis was conducted to assess the potential uncertainties of parameters. RESULTS Of the five competing strategies, alogliptin 25 mg strategy yielded the most significant health outcome, which associated with improvements in discounted QALY of 0.007, 0.014, 0.011, and 0.022 versus linagliptin 5 mg, saxagliptin 5 mg, sitagliptin 100 mg and vildagliptin50 mg, respectively. The sitagliptin 100 mg strategy was the cheapest option. The ICER of alogliptin 25 mg against sitagliptin 100 mg strategy was $6,952 per additional QALY gained, and the rest of the strategies were dominated or extended dominated. The most influential parameters were the cost of DPP-4 inhibitors and their treatment efficacy. CONCLUSIONS These results suggested that alogliptin was a preferred treatment option compared with other DPP-4 inhibitors for Chinese patients whose T2DM are inadequately controlled on metformin monotherapy.
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Affiliation(s)
- Wen-Qiang Lin
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, China
| | - Zhong-jie Cai
- Department of Pharmacy, Mindong Hospital of Ningde City, Fu’an, China
| | - Tingting Chen
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, China
- The School of Pharmacy, Fujian Medical University, Fuzhou, China
| | - Mao-Bai Liu
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, China
- The School of Pharmacy, Fujian Medical University, Fuzhou, China
| | - Na Li
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, China
- The School of Pharmacy, Fujian Medical University, Fuzhou, China
- *Correspondence: Na Li, ; Bin Zheng,
| | - Bin Zheng
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, China
- The School of Pharmacy, Fujian Medical University, Fuzhou, China
- *Correspondence: Na Li, ; Bin Zheng,
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Negm M, Abd El-Razek R. Role of aspirin discontinuation in recurrence of ischemic cerebrovascular stroke. THE EGYPTIAN JOURNAL OF NEUROLOGY, PSYCHIATRY AND NEUROSURGERY 2019. [DOI: 10.1186/s41983-019-0066-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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9
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IL-1α and IL-6 predict vascular events or death in patients with cerebral small vessel disease-Data from the SHEF-CSVD study. Adv Med Sci 2019; 64:258-266. [PMID: 30844663 DOI: 10.1016/j.advms.2019.02.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Revised: 09/02/2018] [Accepted: 02/21/2019] [Indexed: 11/20/2022]
Abstract
PURPOSE The natural clinical course of cerebral small vessel disease (CSVD) was not thoroughly described. The aim of this single center cohort study was to establish biochemical predictors of vascular events and death in CSVD patients during a 24-month follow-up. PATIENTS AND METHODS A total of 130 functionally independent patients with marked MRI features of CSVD and recent lacunar stroke (n = 52,LS), vascular Parkinsonism (n = 28,VaP) or dementia (n = 50,VaD) were prospectively recruited. Serum markers of endothelial dysfunction, inflammation and hemostasis were determined at baseline. The primary outcome was defined as occurrence of death or any vascular events during the observation. RESULTS The mean age was 72 ± 8.1 years, and 37.6% of the patients were women. The mean follow-up time was 22.3 ± 4.3 months, and 84.6% of patients had extensive white matter lesions on baseline MRI. The overall mortality rate was 6.9%, and vascular events or death occurred in 27% of the patients. Kaplan-Meier survival curves revealed no significant differences between CSVD groups (log rank p = 0.49). Cox regression analysis revealed that IL-1α (HR 1.4; 95%CI 1.09-1.8), IL-6 (1.4;1.1-2.2), hs-CRP (1.1;1.06-1.9), homocysteine (1.4;1.1-1.8), fibrinogen (1.4;1.05-2), and d-dimer (2.7;1.6-4.5) were significantly associated with the primary outcome. IL-1α (1.3;1.07-1.8), IL-6 (1.4;1.02-2.2), d-dimer (2.8;1.6-5) and homocysteine (1.4;1.1-1.8) remained significant after adjusting for age, sex and CSVD radiological markers. CONCLUSIONS Our study demonstrated the important prognostic role of various circulation markers of inflammation in individuals with different clinical signs and radiological markers of CSVD. The strongest association occurred between IL-1α, IL-6 and recurrent stroke, other vascular events and death.
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Kozyolkin O, Kuznietsov A, Novikova L. Prediction of the Lethal Outcome of Acute Recurrent Cerebral Ischemic Hemispheric Stroke. MEDICINA-LITHUANIA 2019; 55:medicina55060311. [PMID: 31242700 PMCID: PMC6631068 DOI: 10.3390/medicina55060311] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 06/17/2019] [Accepted: 06/20/2019] [Indexed: 01/04/2023]
Abstract
Background and objectives. Stroke-induced mortality is the third most common cause of death in developed countries. Intense interest has focused on the recurrent ischemic stroke, which rate makes up 30% during first 5 years after first-ever stroke. This work aims to develop criteria for the prediction of acute recurrent cerebral ischemic hemispheric stroke (RCIHS) outcome on the basis of comprehensive baseline clinical, laboratory, and neuroimaging examinations. Materials and Methods. One hundred thirty-six patients (71 males and 65 females, median age 74 (65; 78)) with acute RCIHS were enrolled in the study. All patients underwent a detailed clinical and neurological examination using National Institutes of Health Stroke Scale (NIHSS), computed tomography of the brain, hematological, and biochemical investigations. In order to detect the dependent and independent risk factors of the lethal outcome of the acute period of RCIHS, univariable and multivariable regression analysis were conducted. A receiver operating characteristic (ROC) analysis with the calculation of sensitivity and specificity was performed to determine the prediction variables. Results. Twenty-five patients died. The independent predictors of the lethal outcome of acute RCIHS were: Baseline NIHSS score (OR 95% CІ 1.33 (1.08-1.64), p = 0.0003), septum pellucidum displacement (OR 95% CI 1.53 (1.17-2.00), p = 0.0021), glucose serum level (OR 95% CI 1.28 (1.09-1.50), p = 0.0022), neutrophil-to-lymphocyte ratio (OR 95% CI 1.11 (1.00-1.21), p = 0.0303). The mathematical model, which included these variables was developed and it could determine the prognosis of lethal outcome of the acute RCIHS with an accuracy of 86.8% (AUC = 0.88 ± 0.04 (0.88-0.93), p < 0.0001).
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Affiliation(s)
- Olexandr Kozyolkin
- Department of Nervous Disease Zaporizhzhia State Medical University, 69035 Zaporizhzhia, Ukraine.
| | - Anton Kuznietsov
- Department of Nervous Disease Zaporizhzhia State Medical University, 69035 Zaporizhzhia, Ukraine.
| | - Liubov Novikova
- Department of Nervous Disease Zaporizhzhia State Medical University, 69035 Zaporizhzhia, Ukraine.
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Rosinska J, Maciejewska J, Narożny R, Osztynowicz K, Raczak B, Michalak S, Watała C, Kozubski W, Łukasik M. Effect of acetylsalicylic acid intake on platelet derived microvesicles in healthy subjects. Platelets 2019; 31:206-214. [PMID: 30895834 DOI: 10.1080/09537104.2019.1588242] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Platelet-derived microvesicles (pMVs) are released from platelets in physiological and pathological conditions and exhibit a wide range of prothrombotic, antithrombotic, proatherogenic, and pro-inflammatory properties. Antiplatelet agents, such as acetylsalicylic acid (ASA), are widely used for the prevention and treatment of vascular diseases, but their impact on pMV release remains poorly understood and contradictory mainly because of discrepancies in the methodology and lack of well-standardized MV assessment protocols. The present study investigated the effects of ASA not only on total pMV release but also on their phenotypes defined using the surface expression of pro-inflammatory (CD40L, CD62P, CD31) and procoagulant (PS, PAC-1) markers in healthy subjects. Fifty healthy volunteers were enrolled in the study and received a daily dose of 150 mg ASA for 3 consecutive days. Circulating pMVs were characterized and quantified before and after the intervention period using flow cytometry. Serum levels of thromboxane B2 (TXB2) and whole blood impedance platelet aggregation under arachidonic acid (AA) stimulation were also investigated to assess ASA compliance. In general, ASA did not effect pMV numbers in healthy subjects despite its effective inhibition of platelet aggregation Moreover, in premenopausal women, we noticed an increase in the number of pMVs. Further studies are needed to assess whether dose modification of ASA or combinations or changes in antiplatelet therapy would reduce pMV formation, especially in patients with cardiovascular risk factors.
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Affiliation(s)
- Justyna Rosinska
- Department of Neurology, Poznan University of Medical Sciences, Poznan, Poland
| | - Joanna Maciejewska
- Laboratory of Flow Cytometry and Vascular Biology, Department of Neurology, Poznan University of Medical Sciences, Poznan, Poland
| | - Robert Narożny
- Department of Neurology, Poznan University of Medical Sciences, Poznan, Poland
| | - Krystyna Osztynowicz
- Department of Neurochemistry and Neuropathology, Poznan University of Medical Sciences, Poznan, Poland
| | - Beata Raczak
- Department of Neurochemistry and Neuropathology, Poznan University of Medical Sciences, Poznan, Poland
| | - Sławomir Michalak
- Department of Neurochemistry and Neuropathology, Poznan University of Medical Sciences, Poznan, Poland
| | - Cezary Watała
- Department of Haemostasis and Haemostatic Disorders, Medical University, Lodz, Poland
| | - Wojciech Kozubski
- Department of Neurology, Poznan University of Medical Sciences, Poznan, Poland
| | - Maria Łukasik
- Laboratory of Flow Cytometry and Vascular Biology, Department of Neurology, Poznan University of Medical Sciences, Poznan, Poland
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Recurrence Rate and Relevant Associated Factors of Stroke among Patients with Small Artery Occlusion in Northern China. Sci Rep 2019; 9:2834. [PMID: 30808986 PMCID: PMC6391422 DOI: 10.1038/s41598-019-39207-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Accepted: 01/14/2019] [Indexed: 12/22/2022] Open
Abstract
Small artery occlusion (SAO) is responsible for 31.3% of all ischemic strokes in China. However, reports regarding the recurrence rate of SAO in China are rare. We aimed to assess the recurrence rate and factors associated with SAO in China. All consecutive patients with SAO hospitalized at Tianjin Huanhu Hospital from 2005 to 2014 were recruited. We assessed the association between stroke subtype, severity, and disease history with recurrence at 3, 12, and 36 months of onset using multivariate logistic regression analysis. A total of 2,524 SAO patients were included in this study, including 1696 (67.2%) men and 828 (32.8%) women. The recurrence rates were 3.1% at 3 months, 12.7% at 12 months, and 36.5% at 36 months. Compared with women, men had a higher risk of recurrence at 3 months after SAO (P = 0.003). Old age and severity of stroke were also associated with a higher risk of recurrence (P < 0.05). Patients with an elevated C-reactive protein had a higher risk of recurrence at 12 months (P = 0.003). On the other hand, the risk of recurrence at 12 months was 39% lower in patients who consumed alcohol than in those who did not (P = 0.037). Hypertension, atrial fibrillation, and obesity were independent risk factors of recurrence at 36 months. These findings suggest that modification of risk factors in patients with SAO, particularly men, is essential for reducing the rate of recurrence and the overall burden of stroke in China.
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Rosińska J, Ambrosius W, Maciejewska J, Narożny R, Kozubski W, Łukasik M. Association of platelet-derived microvesicles and their phenotypes with carotid atherosclerosis and recurrent vascular events in patients after ischemic stroke. Thromb Res 2019; 176:18-26. [PMID: 30763823 DOI: 10.1016/j.thromres.2019.01.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 12/21/2018] [Accepted: 01/21/2019] [Indexed: 01/28/2023]
Abstract
INTRODUCTION Platelet-derived microvesicles (pMVs) exhibit procoagulant and proinflammatory properties and play a role in the development and progression of atherosclerosis. The study examined the association between the total number of pMVs and their phenotypes with carotid atherosclerosis and recurrent vascular events (VEs) in patients in the convalescent phase of ischemic stroke (IS). MATERIALS AND METHODS The study group consisted of 72 patients with IS secondary to large artery atherosclerosis (LAA) (n = 40) and small arteries occlusion (SAO) (n = 32) and 69 matched cardiovascular disease risk-factor (RF) controls. Total pMV number, defined as CD61+ microvesicles (MVs), and their phenotypes, defined as the surface expression of proinflammatory (CD40L, CD62P, CD31) and procoagulant (PS, PAC-1) markers, were characterized and quantified using flow cytometry. The mean common carotid intima-media thickness (CCA mean IMT), maximal common carotid IMT (CCA max IMT) and maximal bifurcation IMT (BIF max IMT) were measured bilaterally using B-mode, color Doppler ultrasonography. All study subjects were observed for one-year to establish the occurrence of VEs. RESULTS No differences in pMV parameters between LAA and SAO stroke subjects and between stroke subgroups and controls were found. Stroke patients with carotid atherosclerosis exhibited higher concentration of CD62P+/CD61+ and PAC-1+/CD61+ MVs compared to patients without the atherosclerosis. Positive associations between total number of pMVs, AnV+ MVs and AnV+/CD61+ MVs and atherosclerotic thickening of carotid intima-media in stroke patients were found. Elevated concentration of AnV+/CD61+, PAC-1+/CD61+, CD61P+/CD61+ and CD31+/CD61+ MVs, were revealed in stroke patients who suffered from recurrent VE in one-year follow-up period. Negative correlation of pMVs and CD62P+/CD61+ MVs concentration as well as percentage of total CD61+ in AnV+ population of MVs and time elapsed from IS in convalescent stroke subjects was revealed. CONCLUSION Our results confirm positive correlations between total pMV number, the number of PAC-1+/CD61+ and CD62+/CD61+ MVs and carotid atherosclerosis in stroke subjects. Some pMV parameters may exhibit a predictive value for the next VE in groups with a history of stroke. pMVs and some of their phenotypes decline over time elapsed from stroke in convalescent stroke subjects.
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Affiliation(s)
- Justyna Rosińska
- Department of Neurology, Poznan University of Medical Sciences, Poznan, Poland.
| | - Wojciech Ambrosius
- Department of Neurology, Poznan University of Medical Sciences, Poznan, Poland
| | - Joanna Maciejewska
- Laboratory of Flow Cytometry and Vascular Biology, Department of Neurology, Poznan University of Medical Sciences, Poznan, Poland
| | - Robert Narożny
- Department of Neurology, Poznan University of Medical Sciences, Poznan, Poland
| | - Wojciech Kozubski
- Department of Neurology, Poznan University of Medical Sciences, Poznan, Poland
| | - Maria Łukasik
- Laboratory of Flow Cytometry and Vascular Biology, Department of Neurology, Poznan University of Medical Sciences, Poznan, Poland
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Singh RJ, Chen S, Ganesh A, Hill MD. Long-term neurological, vascular, and mortality outcomes after stroke. Int J Stroke 2018; 13:787-796. [DOI: 10.1177/1747493018798526] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Despite improved survival and short-term (90-day) outcomes of ischemic stroke patients, only sparse data exist describing the sustained benefits of acute stroke care interventions and long-term prognosis of stroke survivors. Aim We review the contemporary literature assessing long-term (5 years or more) outcomes after stroke and acute stroke treatment. Summary of review Acute stroke unit care and intravenous thrombolysis have sustained benefits over longer follow-up, but few data exist on the long-term outcome after endovascular thrombectomy (EVT). A large proportion of stroke survivors face challenges of residual disability and neuropsychiatric sequelae (especially affective disorders and epilepsy) which affects their quality of life and is associated with poorer prognosis due to increase in stroke recurrences/mortality. Nearly, a quarter of stroke survivors have a recurrent stroke at 5 years, and nearly double that at 10 years. Mortality after recurrent stroke is high, and half of the stroke survivors are deceased at 5 years after stroke and three fourth at 10 years. Long-term all-cause mortality is largely due to conditions other than stroke. Both stroke recurrence and long-term mortality are affected by several modifiable risk factors, and thus amenable to secondary prevention strategies. Conclusions There is a need for studies reporting longer term effects of acute interventions, especially EVT. Better preventive strategies are warranted to reduce the vascular and non-vascular mortality long after stroke.
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Affiliation(s)
- Ravinder-Jeet Singh
- Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
| | - Shuo Chen
- Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
| | - Aravind Ganesh
- Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
| | - Michael D Hill
- Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
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15
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Qiao Q, Hong Y, Zhao W, Zhou G, Liu Q, Ning X, Wang J, An Z. Sex differences in outcomes and associated factors among stroke patients with small artery occlusion in China. Biol Sex Differ 2018; 9:35. [PMID: 30071887 PMCID: PMC6090906 DOI: 10.1186/s13293-018-0194-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Accepted: 07/27/2018] [Indexed: 11/26/2022] Open
Abstract
Background Sex differences in outcomes after small artery occlusion (SAO) stroke have not been well described, particularly in a Chinese population. We aimed to assess sex differences in outcomes and related risk factors among patients with SAO. Methods All consecutive patients with SAO were recruited between May 2005 and September 2014. Clinical features and risk factors were recorded. The mortality, recurrence, and dependency rates at 3 months after stroke were assessed. Results A total of 2524 patients with SAO were included in this study. There was a higher frequency of mild stroke, current smoking, and alcohol consumption in men than in women. Women were more likely than men to be older, to have diabetes and obesity, and to have higher total cholesterol, high-density lipoprotein cholesterol, and low-density lipoprotein cholesterol levels. There were worse outcomes in men than in women at 3 months after stroke (P < 0.05). There were more independent risk factors of poor outcome in men than in women. Older age was a common predictive factor of outcome both in men and in women. In men, low triglyceride levels and high fasting plasma glucose levels were independent risk factors for mortality; in addition, a high low-density lipoprotein cholesterol level was associated with recurrence. Moreover, in men, moderate and severe stroke, and high total cholesterol and fasting plasma glucose levels were risk factors for dependency. A negative association was found between low-density lipoprotein cholesterol level and risk of mortality and between total cholesterol level and risk of recurrence in women. Conclusions These findings suggest that it is crucial to control conventional risk factors and fasting plasma glucose and lipid levels among patients with SAO, especially male patients, to reduce the burden of stroke in China.
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Affiliation(s)
- Qing Qiao
- Department of Neurology, Tianjin Huanhu Hospital, 6 Jizhao Road, Jinnan District, Tianjin, 300350, China.,Tianjin Key Laboratory of Cerebral Vascular and Neurodegenerative Disease, 6 Jizhao Road, Jinnan District, Tianjin, 300350, China
| | - Yan Hong
- Department of Neurology, Tianjin Huanhu Hospital, 6 Jizhao Road, Jinnan District, Tianjin, 300350, China. .,Tianjin Key Laboratory of Cerebral Vascular and Neurodegenerative Disease, 6 Jizhao Road, Jinnan District, Tianjin, 300350, China.
| | - Wenjuan Zhao
- Department of Neurology, Tianjin Huanhu Hospital, 6 Jizhao Road, Jinnan District, Tianjin, 300350, China.,Tianjin Key Laboratory of Cerebral Vascular and Neurodegenerative Disease, 6 Jizhao Road, Jinnan District, Tianjin, 300350, China
| | - Guanen Zhou
- Department of Neurology, Tianjin Huanhu Hospital, 6 Jizhao Road, Jinnan District, Tianjin, 300350, China.,Tianjin Key Laboratory of Cerebral Vascular and Neurodegenerative Disease, 6 Jizhao Road, Jinnan District, Tianjin, 300350, China
| | - Qian Liu
- Department of Neurology, Tianjin Huanhu Hospital, 6 Jizhao Road, Jinnan District, Tianjin, 300350, China.,Tianjin Key Laboratory of Cerebral Vascular and Neurodegenerative Disease, 6 Jizhao Road, Jinnan District, Tianjin, 300350, China
| | - Xianjia Ning
- Department of Epidemiology, Tianjin Neurological Institute, 154 Anshan Road, Heping District, Tianjin, 300052, China.,Department of Neurology, Tianjin Medical University General Hospital, 154 Anshan Road, Heping District, Tianjin, 300052, China.,Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin City, 154 Anshan Road, Heping District, Tianjin, 300052, China
| | - Jinghua Wang
- Department of Epidemiology, Tianjin Neurological Institute, 154 Anshan Road, Heping District, Tianjin, 300052, China.,Department of Neurology, Tianjin Medical University General Hospital, 154 Anshan Road, Heping District, Tianjin, 300052, China.,Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin City, 154 Anshan Road, Heping District, Tianjin, 300052, China
| | - Zhongping An
- Department of Neurology, Tianjin Huanhu Hospital, 6 Jizhao Road, Jinnan District, Tianjin, 300350, China. .,Tianjin Key Laboratory of Cerebral Vascular and Neurodegenerative Disease, 6 Jizhao Road, Jinnan District, Tianjin, 300350, China.
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16
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Staszewski J, Piusińska-Macoch R, Brodacki B, Skrobowska E, Macek K, Stępień A. Risk of vascular events in different manifestations of cerebral small vessel disease: A 2-year follow-up study with a control group. Heliyon 2017; 3:e00455. [PMID: 29264414 PMCID: PMC5727612 DOI: 10.1016/j.heliyon.2017.e00455] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2017] [Revised: 10/13/2017] [Accepted: 11/13/2017] [Indexed: 12/29/2022] Open
Abstract
Background and purpose Natural course of cerebral small vessel disease (CSVD) has not yet been thoroughly studied. The aim of the single center study was to establish risk of vascular events or death in different manifestations of CSVD. Methods 150 consecutive, functionally independent patients with marked MRI features of CSVD and with recent lacunar stroke (n = 52, LS), deep hemorrhagic stroke (n = 20, HS), vascular parkinsonism (n = 28, VaP), vascular dementia (n = 50, VaD) and 55 controls (CG) with high atherothrombotic risk free of cerebrovascular events were prospectively recruited and followed for 24 months. Results Mean age and sex distribution were similar in CSVD and CG but patients with CSVD were less likely to have CAD (19% vs 40%, p = 0.02) and tended to have higher prevalence of diabetes (54% vs 37%, p = 0.11). The risk of vascular events or death was increased in any patients with moderate to severe white matter lesions at baseline MRI (HR 2.0; 95% CI 0.85–7.2), in CSVD (4.56; 95% CI 1.3–14.9) vs CG, regardless of its clinical manifestation: LS or HS (HR 4.70; 95% CI 1.3–16.2) and VaD or VaP (HR 4.59; 95% CI 1.3–15.7). Adjustment for confounders did not change the results substantially. Conclusions Patients with symptomatic CSVD regardless of the clinical (acute or chronic) manifestation had more than fourfold the risk of vascular events or death in 24 months of observation compared with controls with high atherothrombotic risk free of cerebrovascular events.
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Affiliation(s)
- Jacek Staszewski
- Clinic of Neurology, Military Institute of Medicine, Szaserow 128, Warsaw 04-141, Poland
- Corresponding author.
| | | | - Bogdan Brodacki
- Clinic of Neurology, Military Institute of Medicine, Szaserow 128, Warsaw 04-141, Poland
| | - Ewa Skrobowska
- Department of Radiology, Military Institute of Medicine, Szaserow 128, Warsaw 04-141, Poland
| | - Katarzyna Macek
- Clinic of Neurology, Military Institute of Medicine, Szaserow 128, Warsaw 04-141, Poland
| | - Adam Stępień
- Clinic of Neurology, Military Institute of Medicine, Szaserow 128, Warsaw 04-141, Poland
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17
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Albright KC, Howard VJ, Howard G, Muntner P, Bittner V, Safford MM, Boehme AK, Rhodes JD, Beasley TM, Judd SE, McClure LA, Limdi N, Blackburn J. Age and Sex Disparities in Discharge Statin Prescribing in the Stroke Belt: Evidence From the Reasons for Geographic and Racial Differences in Stroke Study. J Am Heart Assoc 2017; 6:e005523. [PMID: 28768644 PMCID: PMC5586419 DOI: 10.1161/jaha.117.005523] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2017] [Accepted: 06/15/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Stroke is a costly and debilitating disease that disproportionately affects blacks. Despite the efficacy of statins, evidence suggests racial disparities may exist in statin prescribing. METHODS AND RESULTS We analyzed discharge medications for participants hospitalized for an ischemic stroke during follow-up of the REGARDS (Reasons for Geographic and Racial Differences in Stroke) study. Medications on admission and discharge were abstracted from medical records. Among the 666 eligible incident strokes (2003-2013), analyses were restricted to 323 participants who were not statin users at the time of admission and had no history of atrial fibrillation. Overall, 48.7% were prescribed a statin on discharge. In the Stroke Belt, participants aged 65 years and older were 47% less likely to be discharged on a statin compared with those younger than 65 years (relative risk [RR], 0.53; 95% CI, 0.38-0.74). This association was not observed in non-Stroke Belt residents. Outside the Stroke Belt, blacks were more likely than whites to be discharged on a statin (RR, 1.42; 95% CI, 1.04-1.94), while no black:white association was present among Stroke Belt residents (RR, 0.93; 95% CI, 0.69-1.26; P for interaction=0.228). Compared with women, men in the Stroke Belt were 31% less likely to be discharged on a statin (RR, 0.69; 95% CI, 0.50-0.94) while men outside the Stroke Belt were more likely to be discharged on a statin (RR, 1.38; 95% CI, 0.99-1.92; P for interaction=0.004). CONCLUSIONS Statin discharge prescribing may differ among Stroke Belt and non-Stroke Belt residents, particularly in older Americans and men.
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Affiliation(s)
- Karen C Albright
- Geriatric Research, Education and Clinical Center (GRECC), Birmingham VA Medical Center, Birmingham, AL
- Department of Epidemiology, University of Alabama at Birmingham, AL
| | | | - George Howard
- Department of Biostatistics, University of Alabama at Birmingham, AL
| | - Paul Muntner
- Department of Epidemiology, University of Alabama at Birmingham, AL
| | - Vera Bittner
- Department of Medicine, University of Alabama at Birmingham, AL
| | | | | | - J David Rhodes
- Department of Biostatistics, University of Alabama at Birmingham, AL
| | - T Mark Beasley
- Department of Biostatistics, University of Alabama at Birmingham, AL
| | - Suzanne E Judd
- Department of Biostatistics, University of Alabama at Birmingham, AL
| | - Leslie A McClure
- Department of Biostatistics, University of Alabama at Birmingham, AL
| | - Nita Limdi
- Department of Neurology, University of Alabama at Birmingham, AL
| | - Justin Blackburn
- Department of Health Care Organization & Policy, University of Alabama at Birmingham, AL
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Vascular parkinsonism and vascular dementia are associated with an increased risk of vascular events or death. ACTA ACUST UNITED AC 2017; 2:e16-e23. [PMID: 28905043 PMCID: PMC5596114 DOI: 10.5114/amsad.2017.68549] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Accepted: 06/10/2017] [Indexed: 12/20/2022]
Abstract
Introduction The natural course of vascular parkinsonism (VaP) and dementia (VaD) due to cerebral small vessel disease (SVD) is not well known. The aim of this single-center study was to evaluate the long-term risk of vascular events, death and dependency in patients with VaP or VaD and to compare it with patients without cerebrovascular disease but with high atherothrombotic risk. Material and methods Seventy-eight consecutive, functionally independent patients with MRI features of SVD and with recently diagnosed VaD (n = 50) and VaP (n = 28) and 55 controls (control group – CG) with high 10-year risk of total cardiovascular disease (SCORE ≥ 5%) were prospectively recruited and followed for 24 months. Results Patients with SVD had lower prevalence of coronary artery disease compared with the CG (20.5% vs. 40%; p = 0.02) but similar prevalence of other atherothrombotic risk factors including mean age (73.7 ±7.3 vs. 72 ±5.9 years, p = 0.09). All outcomes were worse in SVD patients than controls. Thirty-one percent of SVD patients (34% of VaD vs. 25% of VaP, p = 0.45) experienced vascular events or died compared to 6% of controls (p < 0.01). After adjustments for potential confounders (age, sex, vascular risk factors), patients with VaP (HR = 7.5; 95% CI: 1.6–33; p < 0.01) and VaD (HR = 8.7; 95% CI: 2.1–35; p < 0.01) had higher risk of vascular events or death and death or dependency (respectively; HR = 3.9; 95% CI: 0.83–18.8; p = 0.07 and HR = 4.7, 95% CI: 1.1–19.7; p = 0.03). Conclusions Patients with VaP or VaD due to SVD had significantly higher risk of vascular events, death and dependency compared to controls with high cardiovascular risk and without cerebrovascular disease.
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19
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Lehtola H, Airaksinen KEJ, Hartikainen P, Hartikainen JEK, Palomäki A, Nuotio I, Ylitalo A, Kiviniemi T, Mustonen P. Stroke recurrence in patients with atrial fibrillation: concomitant carotid artery stenosis doubles the risk. Eur J Neurol 2017; 24:719-725. [DOI: 10.1111/ene.13280] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Accepted: 02/07/2017] [Indexed: 11/30/2022]
Affiliation(s)
- H. Lehtola
- Department of Medicine; Keski-Suomi Central Hospital; Jyvaskyla Finland
| | | | - P. Hartikainen
- Neurology; NeuroCenter; Kuopio University Hospital; Kuopio Finland
| | | | - A. Palomäki
- Heart Center; Turku University Hospital; University of Turku; Turku Finland
| | - I. Nuotio
- Department of Acute Medicine; Turku University Hospital; University of Turku; Turku Finland
| | - A. Ylitalo
- Heart Center; Turku University Hospital; University of Turku; Turku Finland
- Satakunta Central Hospital; Pori Finland
| | - T. Kiviniemi
- Heart Center; Turku University Hospital; University of Turku; Turku Finland
| | - P. Mustonen
- Department of Medicine; Keski-Suomi Central Hospital; Jyvaskyla Finland
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20
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Choi JY, Cha J, Jung JM, Seo WK, Oh K, Cho KH, Yu S. Left ventricular wall motion abnormalities are associated with stroke recurrence. Neurology 2017; 88:586-594. [DOI: 10.1212/wnl.0000000000003588] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2016] [Accepted: 09/30/2016] [Indexed: 11/15/2022] Open
Abstract
Objective:To investigate the role of left ventricular wall motion abnormalities (LVWMA), unrelated to high-risk cardioembolic conditions, in stroke recurrence.Methods:This study included consecutive acute ischemic stroke patients. Transthoracic echocardiography was performed as a routine evaluation for stroke patients. The outcomes were the time to recurrent any stroke and ischemic stroke.Results:Among 4,316 acute ischemic stroke patients, 430 had LVWMA without high-risk cardioembolic sources. The median observation periods of patients at risk of any stroke and ischemic stroke were 24.5 and 24.7 months. During the follow-up, any stroke and ischemic stroke recurrence were observed in 310 (7.2%) and 250 (5.8%) patients. LVWMA were associated with outcomes after adjustment for traditional cardiovascular risk factors, laboratory and imaging variables, and therapeutic interventions (hazard ratio [HR] 1.707, 95% confidence interval [CI] 1.262–2.310 for any stroke; HR 1.709, 95% CI 1.222–2.390 for ischemic stroke). Moreover, LVWMA could still be considered as independent risk factors after correction for covariates that were significantly associated with outcomes in univariable regression (HR 1.747, 95% CI 1.292–2.364 for any stroke; HR 1.704, 95% CI 1.219–2.382 for ischemic stroke). There were no significant interactions between LVWMA and outcomes between the subgroups except for the statin treatment subgroup.Conclusions:This study suggests that LVWMA, even when unassociated with high-risk cardioembolic sources, could be an independent predictor for stroke recurrence in patients with ischemic stroke.
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21
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Eriksson SE. Secondary prophylactic treatment and long-term prognosis after TIA and different subtypes of stroke. A 25-year follow-up hospital-based observational study. Brain Behav 2017; 7:e00603. [PMID: 28127521 PMCID: PMC5256186 DOI: 10.1002/brb3.603] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Revised: 08/29/2016] [Accepted: 10/10/2016] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVES To assess long-term prognosis after transient ischemic attack (TIA)/subtypes of stroke relative to secondary prophylactic treatment(s) given. MATERIALS AND METHODS Retro/prospective follow-up of patients hospitalized in the Stroke Unit or in the Department of Neurology, Linköping, in 1986 and followed up to Feb. 2011. RESULTS A total of 288 men were followed up for 2254 years (mean 7.8 years) and 261 women for 1984 years (mean 7.6 years). In men, the distribution to anticoagulants (AC) (warfarin treatment) was 18%, antiplatelet therapy (APT) usually ASA 75 mg/day 54%, untreated 27%, unknown 2%. In women, the distribution to AC was 15%, APT 60%, untreated 23%, unknown 2%, respectively. Mortality rates at 1 year, 10 years, and 25 years for men were 21%, 67%, and 93%, respectively, versus the rates in women of 24%, 71%, and 90%, respectively. Survival curves showed markedly increased risk of death compared to the normal population. AC treatment was more favorable for men regarding the annual risk of stroke, compared with APT (9.4% vs. 9.8%), as well as the risks of MI, (5.6% vs. 6.7%), and death (8.1% vs. 10.3%), compared to women for stroke (11.6% vs. 8.8%) and MI (5.3% vs. 3.7%) but not for death (8.3% vs. 8.4%). The risk of fatal bleeding was 0.86% annually on AC compared to 0.17% on APT. According to Cox regression analysis included patients with TIA/ischemic stroke, first-line treatment had beneficial effects on survival: AC OR 0.67 (0.5-0.9), APT 0.67 (0.52-0.88) versus untreated. CONCLUSIONS Patients with a history of TIA/stroke had a higher mortality rate versus controls, providing support for both primary and secondary prophylaxis regarding vascular risk factors for death. This study also provided support for secondary prophylactic treatment with either AC or ASA (75 mg once daily) to reduce the vascular risk of death unless there are contraindications.
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Affiliation(s)
- Sven-Erik Eriksson
- Division of Neurology Department of Medicine Falun Hospital Falun Sweden
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22
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Riemsma R, Corro Ramos I, Birnie R, Büyükkaramikli N, Armstrong N, Ryder S, Duffy S, Worthy G, Al M, Severens J, Kleijnen J. Integrated sensor-augmented pump therapy systems [the MiniMed® Paradigm™ Veo system and the Vibe™ and G4® PLATINUM CGM (continuous glucose monitoring) system] for managing blood glucose levels in type 1 diabetes: a systematic review and economic evaluation. Health Technol Assess 2016; 20:v-xxxi, 1-251. [PMID: 26933827 DOI: 10.3310/hta20170] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND In recent years, meters for continuous monitoring of interstitial fluid glucose have been introduced to help people with type 1 diabetes mellitus (T1DM) to achieve better control of their disease. OBJECTIVE The objective of this project was to summarise the evidence on the clinical effectiveness and cost-effectiveness of the MiniMed(®) Paradigm™ Veo system (Medtronic Inc., Northridge, CA, USA) and the Vibe™ (Animas(®) Corporation, West Chester, PA, USA) and G4(®) PLATINUM CGM (continuous glucose monitoring) system (Dexcom Inc., San Diego, CA, USA) in comparison with multiple daily insulin injections (MDIs) or continuous subcutaneous insulin infusion (CSII), both with either self-monitoring of blood glucose (SMBG) or CGM, for the management of T1DM in adults and children. DATA SOURCES A systematic review was conducted in accordance with the principles of the Centre for Reviews and Dissemination guidance and the National Institute for Health and Care Excellence Diagnostic Assessment Programme manual. We searched 14 databases, three trial registries and two conference proceedings from study inception up to September 2014. In addition, reference lists of relevant systematic reviews were checked. In the absence of randomised controlled trials directly comparing Veo or an integrated CSII + CGM system, such as Vibe, with comparator interventions, indirect treatment comparisons were performed if possible. METHODS A commercially available cost-effectiveness model, the IMS Centre for Outcomes Research and Effectiveness diabetes model version 8.5 (IMS Health, Danbury, CT, USA), was used for this assessment. This model is an internet-based, interactive simulation model that predicts the long-term health outcomes and costs associated with the management of T1DM and type 2 diabetes. The model consists of 15 submodels designed to simulate diabetes-related complications, non-specific mortality and costs over time. As the model simulates individual patients over time, it updates risk factors and complications to account for disease progression. RESULTS Fifty-four publications resulting from 19 studies were included in the review. Overall, the evidence suggests that the Veo system reduces hypoglycaemic events more than other treatments, without any differences in other outcomes, including glycated haemoglobin (HbA1c) levels. We also found significant results in favour of the integrated CSII + CGM system over MDIs with SMBG with regard to HbA1c levels and quality of life. However, the evidence base was poor. The quality of the included studies was generally low, often with only one study comparing treatments in a specific population at a specific follow-up time. In particular, there was only one study comparing Veo with an integrated CSII + CGM system and only one study comparing Veo with a CSII + SMBG system in a mixed population. Cost-effectiveness analyses indicated that MDI + SMBG is the option most likely to be cost-effective, given the current threshold of £30,000 per quality-adjusted life-year gained, whereas integrated CSII + CGM systems and Veo are dominated and extendedly dominated, respectively, by stand-alone, non-integrated CSII with CGM. Scenario analyses did not alter these conclusions. No cost-effectiveness modelling was conducted for children or pregnant women. CONCLUSIONS The Veo system does appear to be better than the other systems considered at reducing hypoglycaemic events. However, in adults, it is unlikely to be cost-effective. Integrated systems are also generally unlikely to be cost-effective given that stand-alone systems are cheaper and, possibly, no less effective. However, evidence in this regard is generally lacking, in particular for children. Future trials in specific child, adolescent and adult populations should include longer term follow-up and ratings on the European Quality of Life-5 Dimensions scale at various time points with a view to informing improved cost-effectiveness modelling. STUDY REGISTRATION PROSPERO Registration Number CRD42014013764. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
| | - Isaac Corro Ramos
- Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, the Netherlands
| | | | - Nasuh Büyükkaramikli
- Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, the Netherlands
| | | | | | | | | | - Maiwenn Al
- Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, the Netherlands
| | - Johan Severens
- Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, the Netherlands
| | - Jos Kleijnen
- Kleijnen Systematic Reviews Ltd, York, UK.,School for Public Health and Primary Care, Maastricht University, Maastricht, the Netherlands
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Moerch-Rasmussen A, Nacu A, Waje-Andreassen U, Thomassen L, Naess H. Recurrent ischemic stroke is associated with the burden of risk factors. Acta Neurol Scand 2016; 133:289-94. [PMID: 26177064 DOI: 10.1111/ane.12457] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/15/2015] [Indexed: 11/29/2022]
Abstract
AIM To determine the characteristics of acute ischemic stroke patients admitted to hospital with history of prior ischemic stroke(s). We hypothesized that there is an association between the number of risk factors and prior ischemic stroke irrespective of age. METHODS All patients with acute ischemic stroke admitted to Haukeland University Hospital between 2006 and 2013 were registered in the NORSTROKE database. Variables included prior ischemic stroke(s) (based on self-report and patient records), risk factors, TOAST classification, and CT and MRI findings. Comparison was made between patients with prior ischemic stroke and first-ever ischemic stroke. Multivariate analyses were performed. RESULTS In total, 2697 patients were included and 461 (17.1%) had a history of prior ischemic stroke(s). Logistic regression analyses showed that prior ischemic stroke was associated with the number of risk factors, leukoaraiosis, hypertension, atrial fibrillation, and atherosclerosis. CONCLUSION History of prior ischemic stroke in patients with acute ischemic stroke was associated with the burden of risk factors, atherosclerosis, and atrial fibrillation compared to first-ever ischemic stroke. This has important implications for secondary preventive treatment.
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Affiliation(s)
- A. Moerch-Rasmussen
- Department of Neurology; Haukeland University Hospital; Bergen Norway
- Department of Clinical Medicine; University of Bergen; Bergen Norway
| | - A. Nacu
- Department of Neurology; Haukeland University Hospital; Bergen Norway
- Department of Clinical Medicine; University of Bergen; Bergen Norway
| | | | - L. Thomassen
- Department of Neurology; Haukeland University Hospital; Bergen Norway
- Department of Clinical Medicine; University of Bergen; Bergen Norway
| | - H. Naess
- Department of Neurology; Haukeland University Hospital; Bergen Norway
- Department of Clinical Medicine; University of Bergen; Bergen Norway
- Centre for age-related medicine; Stavanger University Hospital; Stavanger Norway
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25
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Albright KC, Boehme AK, Tanner RM, Blackburn J, Howard G, Howard VJ, Safford M, Beasley TM, Limdi N. Addressing Stroke Risk Factors in Black and White Americans: Findings from the National Health and Nutrition Examination Survey, 2009-2010. Ethn Dis 2016; 26:9-16. [PMID: 26843791 DOI: 10.18865/ed.26.1.9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE Recurrent stroke affects 5%-15% of stroke survivors, is higher among Blacks, and preventable with secondary stroke prevention medications. Our study aimed to examine racial differences in risk factors being addressed (defined as either on active treatment or within guideline levels) among stroke survivors and those at risk for stroke. METHODS A cross-sectional study using NHANES 2009-2010 standardized interviews of Whites and Blacks aged ≥18 years. Risk factors were defined as being addressed if: 1) for hypertension, SBP <140, DBP <90 (SBP<130, DBP<80 for diabetics) or using BP-lowering medications; 2) for current smoking, using cessation medications; and 3) for hyperlipidemia, LDL<100 (LDL<70 for stroke survivors) or using lipid-lowering medications. Participants were stratified by stroke history. Prevalence of addressed risk factors was compared by race. RESULTS Among 4005 participants (mean age 48, 52% women, 15% Black), 4% reported a history of stroke. Among stroke survivors, there were no statistically significant differences in Blacks and Whites having their hypertension or hyperlipidemia addressed. Among stroke naïve participants, the prevalence of addressed hypertension (P<.01) and hyperlipidemia (P<.01) was lower in Blacks compared with Whites. CONCLUSIONS We found that addressed hypertension and hyperlipidemia in stroke naïve participants were significantly lower in Blacks than Whites. Our observations call attention to areas that require further investigation, such as why Black Americans may not be receiving evidence-based pharmacologic therapy for hypertension and hyperlipidemia or why Black Americans are not at goal blood pressure or goal LDL. A better understanding of this information is critical to preventing stroke and other vascular diseases.
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Affiliation(s)
- Karen C Albright
- Health Services and Outcomes Research Center for Outcome and Effectiveness Research and Education (COERE), University of Alabama at Birmingham
| | | | - Rikki M Tanner
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham
| | - Justin Blackburn
- Department of Health Care Organization and Policy, School of Public Health, University of Alabama at Birmingham
| | - George Howard
- Department of Biostatistics, School of Public Health, University of Alabama at Birmingham
| | - Virginia J Howard
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham
| | - Monika Safford
- Division of Preventive Medicine, Department of Medicine, School of Medicine, University of Alabama at Birmingham
| | - T Mark Beasley
- Department of Biostatistics, School of Public Health, University of Alabama at Birmingham
| | - Nita Limdi
- Department of Neurology, School of Medicine, University of Alabama at Birmingham
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Portegies ML, Bos MJ, Hofman A, Heeringa J, Franco OH, Koudstaal PJ, Ikram MA. Role of Prestroke Vascular Pathology in Long-Term Prognosis After Stroke. Stroke 2016; 47:80-7. [DOI: 10.1161/strokeaha.115.011256] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2015] [Accepted: 10/27/2015] [Indexed: 01/23/2023]
Abstract
Background and Purpose—
Mortality after stroke remains high for years, mostly because of cardiovascular causes. Given that cardiovascular pathology plays an important role in causing the initial stroke, such prestroke pathology might also influence the prognosis after stroke. Within the population-based Rotterdam Study, we examined the proportion of deaths after stroke that are attributable to pre-existent cardiovascular risk factors before stroke (the population attributable risk).
Methods—
We examined 1237 patients with first-ever stroke and 4928 stroke-free participants (between 1990 and 2012), matched on age, sex, examination round, and stroke date (index date). Cardiovascular risk factors measured on ≈4 years before index date were used as determinants. Participants were continuously followed up for mortality (≈6 years) after the index date. We calculated separate and combined population attributable risk of hypertension, total cholesterol, high-density lipoprotein-cholesterol, body mass index, diabetes mellitus, smoking, transient ischemic attack, and atrial fibrillation.
Results—
Nine hundred and nineteen patients with stroke and 2654 stroke-free participants died. The combined population attributable risk in patients with stroke was 27% (95% confidence interval, 14%–45%) and in stroke-free participants was 19% (95% confidence interval, 12%–29%). Population attributable risks of diabetes mellitus, smoking, and atrial fibrillation were higher in patients with stroke than in the reference group because of a higher prevalence of risk factors. In addition, people with atrial fibrillation and stroke had a higher hazard ratio for death than those with only atrial fibrillation.
Conclusions—
One quarter of deaths after stroke could theoretically be prevented with rigorous cardiovascular prevention and treatment, but this should preferably start before stroke occurrence. In addition, research into factors explaining the remaining deaths needs to be encouraged.
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Affiliation(s)
- Marileen L.P. Portegies
- From the Department of Epidemiology (M.L.P.P., M.J.B., A.H., J.H., O.H.F., M.A.I.), Neurology (M.L.P.P., P.J.K., M.A.I.), and Radiology (M.A.I.), Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Michiel J. Bos
- From the Department of Epidemiology (M.L.P.P., M.J.B., A.H., J.H., O.H.F., M.A.I.), Neurology (M.L.P.P., P.J.K., M.A.I.), and Radiology (M.A.I.), Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Albert Hofman
- From the Department of Epidemiology (M.L.P.P., M.J.B., A.H., J.H., O.H.F., M.A.I.), Neurology (M.L.P.P., P.J.K., M.A.I.), and Radiology (M.A.I.), Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Jan Heeringa
- From the Department of Epidemiology (M.L.P.P., M.J.B., A.H., J.H., O.H.F., M.A.I.), Neurology (M.L.P.P., P.J.K., M.A.I.), and Radiology (M.A.I.), Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Oscar H. Franco
- From the Department of Epidemiology (M.L.P.P., M.J.B., A.H., J.H., O.H.F., M.A.I.), Neurology (M.L.P.P., P.J.K., M.A.I.), and Radiology (M.A.I.), Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Peter J. Koudstaal
- From the Department of Epidemiology (M.L.P.P., M.J.B., A.H., J.H., O.H.F., M.A.I.), Neurology (M.L.P.P., P.J.K., M.A.I.), and Radiology (M.A.I.), Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - M. Arfan Ikram
- From the Department of Epidemiology (M.L.P.P., M.J.B., A.H., J.H., O.H.F., M.A.I.), Neurology (M.L.P.P., P.J.K., M.A.I.), and Radiology (M.A.I.), Erasmus MC University Medical Center, Rotterdam, The Netherlands
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Chung HK, Cho Y, Do HJ, Oh K, Seo WK, Shin MJ. Plasma phospholipid arachidonic acid and lignoceric acid are associated with the risk of cardioembolic stroke. Nutr Res 2015; 35:1001-8. [PMID: 26452419 DOI: 10.1016/j.nutres.2015.09.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Revised: 09/08/2015] [Accepted: 09/11/2015] [Indexed: 11/19/2022]
Abstract
Cardioembolic (CE) stroke is the most severe subtype of ischemic stroke with high recurrence and mortality. However, there is still little information on the association of plasma fatty acid (FA) with CE stroke. The objective of this study was to test the hypothesis whether the composition of plasma phospholipid FA is associated with the risk of CE stroke. The study subjects were collected from the Korea University Stroke Registry. Twenty-one subjects were selected as CE stroke group, and 39 age- and sex-matched subjects with non-CE stroke were selected as controls. Sociodemographic factors, clinical measurements, and plasma phospholipid FA compositions were compared between the groups. Logistic regression was used to obtain estimates of the associations between the relevant FAs and CE stroke. The result showed that the CE stroke group had higher levels of free FA and lower levels of triglycerides before and after adjustment (all P < .05). In the regression analysis, elaidic acid (18:1Tn9) and arachidonic acid (20:4n6) were positively related, but lignoceric acid (24:0) was negatively related to CE stroke in all constructed models (all P < .05). In conclusion, plasma phospholipid FA composition was associated with CE stroke risk in Korean population, with higher proportions of elaidic acid and arachidonic acid and lower proportion of lignoceric acid in CE stroke.
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Affiliation(s)
- Hye-Kyung Chung
- Severance Institute for Vascular and Metabolic Research, Yonsei University College of Medicine, Seoul 120-749, Republic of Korea
| | - Yoonsu Cho
- Department of Food and Nutrition, Korea University, Seoul 136-701, Republic of Korea; Department of Public Health Sciences, Graduate School, Korea University, Seoul 136-701, Republic of Korea
| | - Hyun Ju Do
- Department of Food and Nutrition, Korea University, Seoul 136-701, Republic of Korea
| | - Kyungmi Oh
- Department of Neurology, College of Medicine, Korea University Guro Hospital, Korea University, Seoul 152-703, Republic of Korea
| | - Woo-Keun Seo
- Department of Neurology, College of Medicine, Korea University Guro Hospital, Korea University, Seoul 152-703, Republic of Korea.
| | - Min-Jeong Shin
- Department of Food and Nutrition, Korea University, Seoul 136-701, Republic of Korea; Department of Public Health Sciences, Graduate School, Korea University, Seoul 136-701, Republic of Korea.
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Amin H, Nowak RJ, Schindler JL. Cardioembolic Stroke: Practical Considerations for Patient Risk Management and Secondary Prevention. Postgrad Med 2015; 126:55-65. [DOI: 10.3810/pgm.2014.01.2725] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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Abstract
Stroke and especially its complications are a leading cause of death. Despite reduced morbidity in some developed countries, mortality in stroke patients is still high worldwide. In the past decades, treatment of acute stroke has focused on early intervention, such as revascularization and cerebral edema prevention. However, long-term clinical observations indicate that poststroke pneumonia, cardiovascular complications, and vascular embolism are the major reasons for the increased death rate after stroke. Few evidence-based data are available currently to guide the management of these complications. Thus, systematic studies of these adverse events are essential and urgent to improve survival after stroke.
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Heller S, Lawton J, Amiel S, Cooke D, Mansell P, Brennan A, Elliott J, Boote J, Emery C, Baird W, Basarir H, Beveridge S, Bond R, Campbell M, Chater T, Choudhary P, Clark M, de Zoysa N, Dixon S, Gianfrancesco C, Hopkins D, Jacques R, Kruger J, Moore S, Oliver L, Peasgood T, Rankin D, Roberts S, Rogers H, Taylor C, Thokala P, Thompson G, Ward C. Improving management of type 1 diabetes in the UK: the Dose Adjustment For Normal Eating (DAFNE) programme as a research test-bed. A mixed-method analysis of the barriers to and facilitators of successful diabetes self-management, a health economic analysis, a cluster randomised controlled trial of different models of delivery of an educational intervention and the potential of insulin pumps and additional educator input to improve outcomes. PROGRAMME GRANTS FOR APPLIED RESEARCH 2014. [DOI: 10.3310/pgfar02050] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BackgroundMany adults with type 1 diabetes cannot self-manage their diabetes effectively and die prematurely with diabetic complications as a result of poor glucose control. Following the positive results obtained from a randomised controlled trial (RCT) by the Dose Adjustment For Normal Eating (DAFNE) group, published in 2002, structured training is recommended for all adults with type 1 diabetes in the UK.AimWith evidence that blood glucose control is not always improved or sustained, we sought to determine factors explaining why some patients benefit from training more than other patients, identifying barriers to successful self-management, while developing other models to make skills training more accessible and effective.FindingsWe confirmed that glycaemic outcomes are not always improved or sustained when the DAFNE programme is delivered routinely, although improvements in psychosocial outcomes are maintained. DAFNE courses and follow-up support is needed to help participants instil and habituate key self-management practices such as regular diary/record keeping. DAFNE graduates need structured professional support following training. This is currently either unavailable or provided ad hoc without a supporting evidence base. Demographic and psychosocial characteristics had minimal explanatory power in predicting glycaemic control but good explanatory power in predicting diabetes-specific quality of life over the following year. We developed a DAFNE course delivered for 1 day per week over 5 weeks. There were no major differences in outcomes between this and a standard 1-week DAFNE course; in both arms of a RCT, glycaemic control improved by less than in the original DAFNE trial. We piloted a course delivering both the DAFNE programme and pump training. The pilot demonstrated the feasibility of a full multicentre RCT and resulted in us obtaining subsequent Health Technology Assessment programme funding. In collaboration with the National Institute for Health Research (NIHR) Diabetes Research Programme at King’s College Hospital (RG-PG-0606-1142), London, an intervention for patients with hypoglycaemic problems, DAFNE HART (Dose Adjustment for Normal Eating Hypoglycaemia Awareness Restoration Training), improved impaired hypoglycaemia awareness and is worthy of a formal trial. The health economic work developed a new type 1 diabetes model and confirmed that the DAFNE programme is cost-effective compared with no structured education; indeed, it is cost-saving in the majority of our analyses despite limited glycated haemoglobin benefit. Users made important contributions but this could have been maximised by involving them with grant writing, delaying training until the group was established and funding users’ time off work to maximise attendance. Collecting routine clinical data to conduct continuing evaluated roll-out is possible but to do this effectively requires additional administrator support and/or routine electronic data capture.ConclusionsWe propose that, in future work, we should modify the current DAFNE curricula to incorporate emerging understanding of behaviour change principles to instil and habituate key self-management behaviours that include key DAFNE competencies. An assessment of numeracy, critical for insulin dose adjustment, may help to determine whether or not additional input/support is required both before and after training. Models of structured support involving professionals should be developed and evaluated, incorporating technological interventions to help overcome the barriers identified above and enable participants to build effective self-management behaviours into their everyday lives.Trial registrationClinicalTrials.gov NCT01069393.FundingThe NIHR Programme Grants for Applied Research programme.
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Affiliation(s)
- Simon Heller
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Julia Lawton
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
| | | | - Debbie Cooke
- Division of Psychology, University College London, London, UK
| | - Peter Mansell
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Alan Brennan
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Jackie Elliott
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Jonathan Boote
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
- Centre for Research into Primary and Community Care, University of Hertfordshire, Hatfield, UK
| | - Celia Emery
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Wendy Baird
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Hasan Basarir
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Susan Beveridge
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Rod Bond
- School of Psychology, University of Sussex, Brighton, UK
| | - Mike Campbell
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Timothy Chater
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | | | - Marie Clark
- Division of Psychology, University College London, London, UK
| | | | - Simon Dixon
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | | | | | - Richard Jacques
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Jen Kruger
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Susan Moore
- Northumbria Healthcare NHS Foundation Trust, North Shields, UK
| | - Lindsay Oliver
- Northumbria Healthcare NHS Foundation Trust, North Shields, UK
| | - Tessa Peasgood
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - David Rankin
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Sue Roberts
- Northumbria Healthcare NHS Foundation Trust, North Shields, UK
| | | | - Carolin Taylor
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Praveen Thokala
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Gill Thompson
- Northumbria Healthcare NHS Foundation Trust, North Shields, UK
| | - Candice Ward
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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Liu X, Chen X, Wang H, Pan S. Prognostic significance of admission levels of cardiac indicators in patients with acute ischaemic stroke: prospective observational study. J Int Med Res 2014; 42:1301-10. [PMID: 25332230 DOI: 10.1177/0300060514549217] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE The performance of cardiac indicators as determinants of stroke outcomes remains debatable, therefore the present study focused on the short-term prognostic value of cardiac indicators in patients who had experienced acute ischaemic stroke. METHODS Consecutive patients with acute ischaemic stroke were enrolled in a prospective stroke registry. Data on demographics, clinical characteristics and cardiac indicator levels (including troponin I, creatine kinase-MB, myoglobin and brain natriuretic peptide) were prospectively collected. Receiver operating characteristic curves and binary logistic regression models were used to examine the performance of variables in predicting poor functional outcomes (modified Rankin Scale score 2-6). RESULTS Out of 337 patients with acute ischaemic stroke, myoglobin had the greatest power for predicting poor outcomes among the cardiac indicators. Forward stepwise multivariate logistic regression analysis revealed that myoglobin could independently predict short-term outcomes. Spearman's rank correlation tests indicated a positive correlation between myoglobin levels and stroke severity. CONCLUSIONS Among cardiac indicators, myoglobin may be an independent predictor of short-term outcomes in patients with acute ischaemic stroke.
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Affiliation(s)
- Xuan Liu
- Department of Emergency, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Xiangjun Chen
- Department of Neurology, Huashan Hospital, Fudan University School of Medicine, Shanghai, China
| | - Hairong Wang
- Department of Emergency, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Shuming Pan
- Department of Emergency, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
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Kim YD, Song D, Kim EH, Lee KJ, Lee HS, Nam CM, Nam HS, Heo JH. Long-term mortality according to the characteristics of early neurological deterioration in ischemic stroke patients. Yonsei Med J 2014; 55:669-75. [PMID: 24719133 PMCID: PMC3990074 DOI: 10.3349/ymj.2014.55.3.669] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2013] [Revised: 08/14/2013] [Accepted: 09/02/2013] [Indexed: 11/27/2022] Open
Abstract
PURPOSE Although early neurological deterioration (END) during the acute stroke period is known to be associated with poor functional outcomes, there is little data regarding the impact of END on long-term outcomes according to the characteristics of END. The aim of this study was to investigate whether there are differences in long-term mortality according to the characteristics of END among acute ischemic stroke or transient ischemic attack patients. MATERIALS AND METHODS END was defined as any increase (≥1) in National Institute of Health Stroke Scale score within 7 days after admission. We assessed the characteristics of END, such as the etiology and severity of END, as well as recovery after END. The relationship between 30-day or long-term mortality and each characteristic of END was investigated using multiple logistic analysis or Cox regression model. RESULTS Among 2820 patients, END was observed in 344 patients (12.2%). After adjustment for age, sex, underlying cardiovascular diseases, stroke severity, and stroke subtypes, END was associated with long-term mortality, whether it was mild or severe and whether or not it was followed by recovery. However, 30-day mortality was strongly related to the severity of END or the absence of recovery after END. Among the causes of END, recurrent stroke and medical illness were related to 30-day mortality, as well as long-term mortality, while brain herniation and intracranial hemorrhagic complications were only associated with 30-day mortality. CONCLUSION The results of the present study demonstrated that END is associated with higher mortality and the effects of END on short-term and long-term mortality depend on END characteristics.
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Affiliation(s)
- Young Dae Kim
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Dongbeom Song
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Eun Hye Kim
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Ki Jeong Lee
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Hye Sun Lee
- Department of Biostatistics, Yonsei University College of Medicine, Seoul, Korea
| | - Chung Mo Nam
- Department of Preventive Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Hyo Suk Nam
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Ji Hoe Heo
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
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Chen HF, Li CY, Lee SP, Kwok YT, Chu YT. Improving the One-Year Mortality of Stroke Patients: An 18-Year Observation in a Teaching Hospital. TOHOKU J EXP MED 2014; 232:47-54. [DOI: 10.1620/tjem.232.47] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Hua-Fen Chen
- Department of Endocrinology, Far Eastern Memorial Hospital
- School of Medicine, Fujen Catholic University
| | - Chung-Yi Li
- Department of Public Health, College of Medicine, National Cheng Kung University
- Department of Public Health, China Medical University
| | - Siu-Pak Lee
- Department of Neurology, Far Eastern Memorial Hospital
| | - Yam-Ting Kwok
- Department of Neurology, Far Eastern Memorial Hospital
| | - Yiu-Tong Chu
- Department of Neurology, Far Eastern Memorial Hospital
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Achterberg S, Pruissen D, Kappelle L, Algra A. Risk of Vascular Events after Nondisabling Small and Large Vessel Cerebral Ischemia. Cerebrovasc Dis 2013; 36:190-5. [DOI: 10.1159/000353675] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2013] [Accepted: 06/11/2013] [Indexed: 11/19/2022] Open
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Kim CK, Jung S, Yoon BW. Practical Issues to Prevent Stroke Associated with Non-valvular Atrial Fibrillation. J Stroke 2013; 15:144-52. [PMID: 24396808 PMCID: PMC3859006 DOI: 10.5853/jos.2013.15.3.144] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2013] [Revised: 09/10/2013] [Accepted: 09/11/2013] [Indexed: 11/11/2022] Open
Abstract
Stroke associated with non-valvular atrial fibrillation (NVAF) is one of the most important subtypes of ischemic stroke, and its importance is becoming even more apparent in an aging population. To assess the risk of stroke associated with NVAF, the CHADS2 and CHA2DS2-VASc scores are mainly used. Such scores can be used to predict the recurrence and prognosis of ischemic stroke. In addition, new oral anticoagulants (NOACs) and devices are being evaluated in the prevention of stroke associated with NVAF in addition to treatment with the conventional oral anticoagulant, warfarin. Since clinical experience with NOACs is not globally sufficient, a cautious approach is needed.
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Affiliation(s)
- Chi Kyung Kim
- Department of Neurology, and Clinical Research Center for Stroke, Biomedical Research Institute, Seoul National University Hospital, Seoul, Korea
| | - Seunguk Jung
- Department of Neurology, and Clinical Research Center for Stroke, Biomedical Research Institute, Seoul National University Hospital, Seoul, Korea
| | - Byung-Woo Yoon
- Department of Neurology, and Clinical Research Center for Stroke, Biomedical Research Institute, Seoul National University Hospital, Seoul, Korea
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Fernandes TG, Goulart AC, Santos-Junior WR, Alencar AP, Benseñor IM, Lotufo PA. Educational levels and the functional dependence of ischemic stroke survivors. CAD SAUDE PUBLICA 2013; 28:1581-90. [PMID: 22892977 DOI: 10.1590/s0102-311x2012000800016] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2011] [Accepted: 05/03/2012] [Indexed: 11/21/2022] Open
Abstract
We evaluated the functional dependence of stroke survivors from the Study of Stroke Mortality and Morbidity, using the Rankin Scale. Out of 355 ischemic stroke survivors (with a mean age of 67.9 years), 40% had some functional dependence at 28 days and 34.4% had some functional dependence at 6 months. Most predictors of physical dependence were identified at 28 days. These predictors were: low levels of education [illiterate vs. ≥ 8 years of education, multivariate odds ratio (OR) = 3.7; 95% confidence interval (95%CI): 1.60-8.54] and anatomical stroke location (total anterior circulation infarct, OR = 16.9; 95%CI: 2.93-97.49). Low levels of education and ischemic brain injury influenced functional dependence in these stroke survivors. Our findings reinforce the necessity of developing strategies for the rehabilitation of stroke patients, more especially in formulating specific strategies for care and treatment of stroke survivors with low socioeconomic status.
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Fernandes TG, Goulart AC, Campos TF, Lucena NMG, Freitas KLA, Trevisan CM, Benseñor IM, Lotufo PA. Early stroke case-fatality rates in three hospital registries in the Northeast and Southeast of Brazil. ARQUIVOS DE NEURO-PSIQUIATRIA 2012; 70:869-73. [DOI: 10.1590/s0004-282x2012001100009] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/15/2012] [Accepted: 08/22/2012] [Indexed: 11/21/2022]
Abstract
Few studies have addressed early cerebrovascular lethality in Brazil. OBJECTIVE: To evaluate 10 and 28-day stroke case-fatality rates in three hospitals in three Brazilian cities. METHODS: We described the stroke registries in São Paulo, João Pessoa, and Natal. RESULTS: Out of a total of 962 first-ever events (mean age, 68.1 years-old; 53% men), 83.6% (804 cases) were classified as ischemic and 16.4% (158) as hemorrhagic stroke. Overall, the case-fatality rates and 95% confidence intervals (95%CI) for hemorrhagic stroke events were higher than for ischemic events, both at 10 (12.3%; 95%CI 7.2-17.4 versus 7.0%; 95%CI 5.3-8.8) and at 28 days (19.8%; 95%CI 13.6-26.0 versus 11.1%; 95%CI 8.9-13.3). CONCLUSIONS: We did not find any substantial differences in early case-fatality rates according to stroke subtypes, when comparing the three centers.
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Amin M, Gamal A, Ali M, Awad O. Cardiac troponin T: A sensitive and specific indicator of myocardial injury in patients with cerebrovascular stroke. Egypt Heart J 2012. [DOI: 10.1016/j.ehj.2011.08.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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Cardioembolic stroke is frequent in late recurrence after transient ischemic attack. J Stroke Cerebrovasc Dis 2012; 22:822-7. [PMID: 22795086 DOI: 10.1016/j.jstrokecerebrovasdis.2012.05.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2012] [Revised: 05/18/2012] [Accepted: 05/25/2012] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Transient ischemic attack (TIA) is often followed by a stroke episode. Differences between early and late recurrent stroke, however, have not been elucidated. METHODS We enrolled 133 consecutive patients with acute ischemic stroke who presented to our hospital and had previously been diagnosed with TIA. They were divided into 5 groups according to the interval between TIA and subsequent stroke: <48 hours (group 1); 48 hours to 1 week (group 2); 1 week to 1 month (group 3); 1 month to 3 months (group 4); and >3 months (group 5). Patients who underwent recurrent stroke within and after 1 week subsequent to TIA (the early and late recurrence groups, respectively) were compared with regard to clinical findings. RESULTS Of the 133 patients, 46 (34.6%) were in group 1, 29 (21.8%) in group 2, 23 (17.3%) in group 3, 18 (13.5%) in group 4, and 17 (12.8%) in group 5. Most of the noncardioembolic strokes were observed shortly after TIA, while the percentage of cardioembolic stroke remained high even after long post-TIA periods. The prevalence of atrial fibrillation (AF) was higher in the late recurrence group than in the early recurrence group (41.4% v 24.0%, P = .033). Among 42 patients with AF, 12 (28.6%) were newly diagnosed at the time of stroke. CONCLUSIONS The frequency of cardioembolic stroke did not decline as time after TIA passed. More than one quarter of AF patients had been asymptomatic before stroke, suggesting the need for repeated examinations to detect AF in patients with TIA of unknown etiology.
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Ustrell X, Pellisé A. Cardiac workup of ischemic stroke. Curr Cardiol Rev 2011; 6:175-83. [PMID: 21804776 PMCID: PMC2994109 DOI: 10.2174/157340310791658721] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2010] [Revised: 04/10/2010] [Accepted: 05/25/2010] [Indexed: 12/31/2022] Open
Abstract
Stroke is the leading cause of disability in developed countries and the third cause of mortality. Up to 15-30% of ischemic strokes are caused by cardiac sources of emboli being associated with poor prognosis and high index of fatal recurrence. In order to establish an adequate preventive strategy it is crucial to identify the cause of the embolism. After a complete diagnostic workup up to 30% of strokes remain with an undetermined cause, and most of them are attributed to an embolic mechanism suggesting a cardiac origin.There is no consensus in the extent and optimal approach of cardiac workup of ischemic stroke. Clinical features along with brain imaging and the study of the cerebral vessels with ultrasonography or MRI/CT based angiography can identify other causes or lead to think about a possible cardioembolic origin.Atrial fibrillation is the most common cause of cardioembolic stroke. Identification of occult atrial fibrillation is essential. Baseline ECG, serial ECG('s), cardiac monitoring during the first 48 hours, and Holter monitoring have detection rates varying from 4 to 8% each separately. Extended cardiac monitoring with event loop recorders has shown higher rates of detection of paroxysmal atrial fibrillation.Cardiac imaging with echocardiography is necessary to identify structural sources of emboli. There is insufficient data to determine which is the optimal approach. Transthoracic echocardiography has an acceptable diagnostic yield in patients with heart disease but transesophageal echocardiography has a higher diagnostic yield and is necessary if no cardiac sources have been identified in patients with cryptogenic stroke with embolic mechanism.
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Affiliation(s)
- Xavier Ustrell
- Stroke Unit, Neurology Department, Joan XXIII University Hospital, Tarragona, Catalonia, Spain
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Whiting R, Shen Q, Hung WT, Cordato D, Chan DKY. Predictors for 5-year survival in a prospective cohort of elderly stroke patients. Acta Neurol Scand 2011; 124:309-16. [PMID: 21241254 DOI: 10.1111/j.1600-0404.2010.01476.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To examine predictors for 5-year survival in elderly stroke patients. MATERIALS AND METHODS Prospective cohort study of 186 consecutive acute stroke patients aged ≥65 years admitted to Bankstown-Lidcombe Hospital, Australia 03/2002 to 03/2003. All subjects were followed up in 2007/8, at 5 years post-stroke, for outcome measures. Logistic regression analysis was performed to predict 5-year survival using covariables, including functional status, age, stroke type and severity and vascular risk factors. Patients lost to follow-up (n = 20) were excluded from the analyses. RESULTS One hundred patients (60%) were dead at study end. Predictors for survival in final logistic regression model were as follows: Glasgow Coma Scale (GCS) on admission (OR 1.49, 95%CI 1.1-2.0, P = 0.01), preadmission functional independence measure (FIM) score (OR 1.04, 95%CI 1.0-1.1, P = 0.01), age (OR 0.93, 95%CI 0.87-0.98, P = 0.01) and atrial fibrillation (OR 0.43, 95% CI 0.19-0.95, P = 0.04). For 5-year survivors, mean Modified Rankin Scale was 3.1 ± 1.5, total FIM score 85 ± 32, mini-mental state examination (MMSE) 22 ± 8 and Hospital Anxiety and Depression (HAD) scores 5.4 ± 3.4 and 5.2 ± 3.9, respectively. FIM cognition score was significantly lower at 5 years when compared to baseline (24 ± 8 vs 29 ± 8, P < 0.05) (all scores expressed as mean ± SD). In contrast, MMSE, HAD and total FIM scores were not significantly different at 5 years when compared to baseline. CONCLUSIONS The study identified lower GCS on admission, lower preadmission FIM score, age and atrial fibrillation as negative predictors for 5-year survival following stroke.
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Affiliation(s)
- R Whiting
- Department of Clinical Geratology, John Radcliffe Hospital, Oxford, UK
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Ntaios G, Michel P. Temporal Distribution and Magnitude of the Vulnerability Period around Stroke Depend on Stroke Subtype. Cerebrovasc Dis 2011; 32:246-53. [DOI: 10.1159/000329313] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2011] [Accepted: 05/11/2011] [Indexed: 11/19/2022] Open
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Ramos-Estebanez C, Moral-Arce I, Gonzalez-Mandly A, Dhagubatti V, Gonzalez-Macias J, Munoz R, Hernadez-Hernandez JL. Vascular cognitive impairment in small vessel disease: clinical and neuropsychological features of lacunar state and Binswanger's disease. Age Ageing 2011; 40:175-80. [PMID: 21239411 DOI: 10.1093/ageing/afq169] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND ischaemic cerebrovascular small vessel disease (SVD) is a prevalent and under-diagnosed condition that triggers vascular cognitive impairment (VCI). OBJECTIVE to describe the neuropsychological and clinical profiles in SVD (Binswanger's disease, BD; lacunar state, LS) from the clinician's perspective at the VCI stage. METHODS a total of 1257 patients admitted to a tertiary center with a diagnosis of stroke, neuroradiological vascular disease, cognitive impairment/dementia, during a 13-year period were investigated. We prospectively assessed cognition in a subset of 141 patients with VCI (LS n = 28, BD n = 69, large vessel disease-LVD-n = 44) with MMSE, CAMDEX-H, WAIS-R, EXIT-25 and Trail making test. RESULTS executive dysfunction (ECD) (n = 89, 91.7% versus n = 10, 22.7%; P < 0.001) and gait disturbances (n = 74, 76.3% versus n = 15, 34.1%; P < 0.001) characterized SVD. Prior strokes (n = 9, 9.3% versus n = 23, 52.3%; P < 0.001) and embologenous cardiopathy (n = 39, 40.2% versus n = 28, 63.6%; P < 0.04) featured LVD cases. BD was defined by hypertension (n = 52, 75.4% versus n = 30, 44.1%; P < 0.001), ECD (n = 65, 94.2% versus n = 34, 47.2%; P < 0.001) and VCI onset with cognitive impairment but not strokes (n = 44, 63.8% versus n = 34, 50%; P < 0.01). CONCLUSIONS ECD and a frontal gait are SVD's clinical landmarks in our sample. LS and BD cases share a similar cognitive profile.
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MESH Headings
- Aged
- Aged, 80 and over
- Cerebrovascular Disorders/complications
- Cerebrovascular Disorders/diagnostic imaging
- Cerebrovascular Disorders/physiopathology
- Cerebrovascular Disorders/psychology
- Cognition
- Cognition Disorders/diagnostic imaging
- Cognition Disorders/etiology
- Cognition Disorders/physiopathology
- Cognition Disorders/psychology
- Dementia, Multi-Infarct/diagnostic imaging
- Dementia, Multi-Infarct/etiology
- Dementia, Multi-Infarct/physiopathology
- Dementia, Multi-Infarct/psychology
- Dementia, Vascular/diagnostic imaging
- Dementia, Vascular/etiology
- Dementia, Vascular/physiopathology
- Dementia, Vascular/psychology
- Early Diagnosis
- Executive Function
- Female
- Gait Disorders, Neurologic/etiology
- Gait Disorders, Neurologic/physiopathology
- Humans
- Hypertension/etiology
- Hypertension/physiopathology
- Logistic Models
- Male
- Neuropsychological Tests
- Odds Ratio
- Predictive Value of Tests
- Prospective Studies
- Risk Assessment
- Risk Factors
- Severity of Illness Index
- Spain
- Tomography, X-Ray Computed
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Affiliation(s)
- Ciro Ramos-Estebanez
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA.
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Suto Y, Kowa H, Nakayasu H, Awaki E, Saito J, Irizawa Y, Nakashima K. Relationship between three-year survival and functional outcome at discharge from acute-care hospitals in each subtype of first-ever ischemic stroke patients. Intern Med 2011; 50:1377-83. [PMID: 21720056 DOI: 10.2169/internalmedicine.50.4498] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND We studied the relationship between survival prognosis and the functional outcome at discharge from acute-care hospitals in each subtype of ischemic stroke patients. METHODS A total of 853 consecutive patients with first-ever ischemic stroke, recruited from December 1999 to November 2002, were followed for 725.8 ± 430.0 days. Functional outcome was scored using the modified Rankin scale (mRS). Survival analysis was performed using Kaplan-Meier curves, log rank test, and Cox regression model. RESULTS The respective mortality of the groups with mRS scores of 0-2, 3, 4, and 5 were 13.1%, 25.0%, 47.2% (p<0.05), and 74.0% (p<0.05) in cardioembolic infarction (CEI) patients; 11.3%, 6.9%, 5.6%, and 46.7% (p<0.05) in atherothrombotic infarction (ATI) patients; 8.5%, 5.6%, 11.1%, and 0% (no patient) in lacunar infarction (LACI) patients; and 2.6%, 3.0%, 23.3% (p<0.05), and 28.9% (p<0.05) in infarction of unknown cause (IUC) patients. Multi-variate analysis showed that the mRS score was a significant predictive factor for death in CEI patients, and tended to be a predictive factor for death in ATI patients, or IUC patients. CONCLUSION Functional outcome at discharge from acute-care hospitals may predict the survival prognosis of each subtype of ischemic stroke.
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Affiliation(s)
- Yutaka Suto
- Division of Neurology, Department of Brain and Neurosciences, Faculty of Medicine, Tottori University, Japan.
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Schmieder RE. End organ damage in hypertension. DEUTSCHES ARZTEBLATT INTERNATIONAL 2010; 107:866-73. [PMID: 21191547 DOI: 10.3238/arztebl.2010.0866] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/28/2009] [Accepted: 12/23/2009] [Indexed: 01/19/2023]
Abstract
BACKGROUND End organ damage in hypertension can be detected early, reflects accurately the hypertensive patient's overall cardiovascular risk, and should be prevented and treated with antihypertensive treatment. METHOD We selectively review the relevant literature since 1995, including the German and European guidelines for the diagnosis and treatment of arterial hypertension. RESULTS Measurement of the intima-media thickness in the common carotid artery and of the pulse-wave velocity is now recommended for the early diagnosis of hypertensive vasculopathy. Left ventricular hypertrophy, an important component of hypertensive heart disease, can be diagnosed by echocardiography and with the aid of new electrocardiographic indices. Early signs of hypertensive nephropathy, namely albuminuria and a decreased glomerular filtration rate, are prognostically valuable and easy to detect. Cerebrovascular damage, including early microangiopathic changes, is best diagnosed by magnetic resonance imaging. The treatment of end organ damage due to hypertension centers on blood pressure reduction. Blockade of the renin angiotensin-aldosterone system is an essential part of the treatment of early end organ damage. CONCLUSION Hypertensive end organ damage can now be diagnosed early and reversed with specific and aggressive treatment.
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Affiliation(s)
- Roland E Schmieder
- Nephrologie und Hypertensiologie, Universitätsklinikum Erlangen, 91054 Erlangen, Germany.
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Rønning OM, Stavem K. Predictors of mortality following acute stroke: a cohort study with 12 years of follow-up. J Stroke Cerebrovasc Dis 2010; 21:369-72. [PMID: 21075646 DOI: 10.1016/j.jstrokecerebrovasdis.2010.09.012] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2010] [Revised: 09/29/2010] [Accepted: 09/30/2010] [Indexed: 11/26/2022] Open
Abstract
In this study, we investigated predictors for long-term all-cause mortality in a cohort of patients hospitalized for acute stroke. We prospectively followed 550 patients aged ≥ 60 years who were consecutively admitted within 24 hours of sustaining acute stroke. The patients were followed for 12 years or until death, whichever came first. Multivariate Cox regression models were used to analyze predictors of all-cause mortality, with the following independent variables: age, sex, living alone, previous stroke, ischemic heart disease, atrial fibrillation, hypertension, diabetes, cancer, current smoker, hemorrhagic stroke, treatment in an acute stroke unit, and stroke severity (measured with the Scandinavian Stroke Scale). The 12-year mortality rate was 86.5%. In a multivariate model, all-cause mortality was associated with the following variables: age (hazard ratio, 1.08; 95% confidence interval, 1.07-1.10), male sex (1.69, 1.40-2.05), previous stroke (1.34, 1.08-1.65), ischemic heart disease (1.30, 1.02-1.64), diabetes (1.74, 1.36-2.23), hemorrhagic stroke (1.58, 1.20-2.08), and stroke severity (1.03, 1.03-1.04); Age, male sex, stroke severity, ischemic heart disease, diabetes, and hemorrhagic stroke were all independently associated with an increased risk of all-cause mortality over the 12-year period after stroke.
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Affiliation(s)
- Ole Morten Rønning
- Department of Neurology, Medical Division, Akershus University Hospital, Lørenskog, Norway.
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Allen NB, Holford TR, Bracken MB, Goldstein LB, Howard G, Wang Y, Lichtman JH. Trends in one-year recurrent ischemic stroke among the elderly in the USA: 1994-2002. Cerebrovasc Dis 2010; 30:525-32. [PMID: 20881382 DOI: 10.1159/000319028] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2009] [Accepted: 06/25/2010] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND AND PURPOSE Of the 795,000 strokes occurring in the USA each year, over 20% are recurrent events. Little is known about how the rates of recurrent stroke in the country have changed over time. Our objective was to determine national trends in 1-year recurrent ischemic stroke rates by US county among the elderly from 1994 to 2002. METHODS One-year recurrent stroke rates following incident ischemic stroke (ICD-9 433, 434, 436) among all fee-for-service Medicare beneficiaries were determined by US county for 1994-1996, 1997-1999, and 2000-2002. Bayesian spatiotemporal Poisson modeling was used to determine county-specific trends in recurrent stroke rates over time with risk adjustment for demographics, medical history and comorbid conditions. RESULTS The analysis included more than 2.5 million beneficiaries (56% women; mean age: 78 years; 87% white; n = 957,933 for 1994-1996; n = 838,330 for 1996-1999; n = 895,916 for 2000-2002) aggregated to all 3,118 US counties. After adjustment for changing patient demographics and comorbidities, there was a 4.5% decrease in recurrent stroke rates from 1994-1996 (13.2%) to 2000-2002 (12.6%; p for trend <0.0001). The geographic and temporal patterns were not uniform; the recurrent stroke rates decreased within sections of the Southeast (the 'stroke belt'), but increased in counties in the middle and western sections of the USA. CONCLUSIONS The overall recurrent ischemic stroke rates declined by almost 5% from 1994 to 2002, but temporal patterns varied markedly by region. Additional research is needed to identify the reasons for this geographic disparity.
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Affiliation(s)
- Norrina B Allen
- Division of Chronic Disease Epidemiology, Yale University School of Medicine, New Haven, CT 06520-8034, USA
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Abstract
BACKGROUND AND PURPOSE The aim of the study was to search for differences between clinical characteristics of recurrent ischaemic stroke which occurred within the fifth year after the first event or later, and early recurrence, i.e. within the first year after first-ever ischaemic stroke. We also tried to determine prognostic factors of late recurrent ischaemic episodes. MATERIAL AND METHODS The patients were divided into two groups: group I comprised 124 individuals with recurrence within the first year, and group II - 98 individuals in whom the recurrent episode appeared within the fifth year or later. RESULTS A significantly higher percentage of patients in group I demonstrated evident stenosis (70% or more) of internal carotid artery ipsilateral to stroke (p = 0.023). In this group more cardioembolic strokes were found compared to group II, while in the latter, predominantly lacunar strokes appeared (p = 0.046 and 0.0002, respectively). Group II patients significantly more frequently reported acetylsalicylic acid application, including systematic drug use (p = 0.001). No evident differences were found between groups considering other important non-modifiable and modifiable risk factors of stroke. CONCLUSIONS Small differences between risk factors of ischaemic stroke profiles in patients with early and late recurrent episodes do not allow us to distinguish unequivocally a group of patients with better prognosis regarding the time of recurrent stroke. Use of antiplatelet drugs, either systematic or non-systematic, and lacunar stroke are independent, positive prognostic factors of delay of potential recurrent stroke.
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Chang KC, Lee HC, Tseng MC, Huang YC. Three-year survival after first-ever ischemic stroke is predicted by initial stroke severity: A hospital-based study. Clin Neurol Neurosurg 2010; 112:296-301. [PMID: 20106589 DOI: 10.1016/j.clineuro.2009.12.016] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2009] [Revised: 12/02/2009] [Accepted: 12/23/2009] [Indexed: 11/17/2022]
Abstract
OBJECTIVE We aimed to report 3-year survival and causes of death of first-ever ischemic stroke stratified by initial stroke severity. STUDY DESIGN AND SETTING From September 1998 to October 1999, 360 acute first-ever ischemic stroke patients consecutively admitted were followed up prospectively. Patients' vital status and causes of death were identified from the National Death Registry, till December 31, 2002. Potential prognostic factors available at admission were evaluated using Cox proportional hazards regression analysis with bootstrap validation. RESULTS Three hundred and sixty patients, 58% males with age 64.9 years on average, were followed up for 43.4 months with no lost follow-up. Ninety-two (25.6%) patients died, 25 in the first month. The cumulative case-fatality rates were 12.2%, 15.8%, 20.5% and 25.6% for years 1-4. The proportion of vascular deaths was 84% during the first 30 days and 71% for the subsequent 5 months. The hazard ratio (95% CI) was 1.08 (1.05-1.11) for age (1-year increment), 335.90 (20.72-5446.23) for NIHSS 16-38, 2.48 (1.39-4.42) for NIHSS 7-15, and 0.95 (0.91-0.99) for an interaction term of age and NIHSS 16-38. CONCLUSION This study confirmed that the initial stroke severity and age were early prognostic factors for 3-year survival after first-ever ischemic stroke, and further demonstrated that the influence of age on survival time was slightly lower in patients with severe stroke.
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Affiliation(s)
- Ku-Chou Chang
- Division of Cerebrovascular Diseases, Department of Neurology, Chang Gung Memorial Hospital, Kaohsiung, Taiwan
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